What is Medical Necessity, and How Does it Impact Coverage?
When a healthcare provider prescribes a test or course of treatment, you might assume that whatever the doctor orders for you is Medically Necessary simply because the doctor has ordered it. However, when it comes to what is covered under the Health Plan—which determines how much you pay out-of-pocket for services—the term “Medically Necessary” is specifically defined and one with which you should be familiar.
The Health Plan only covers services determined to be Medically Necessary. The Health Plan defines a treatment, service or supply as Medically Necessary when it is:
- Consistent with generally accepted medical practice within the medical community for the diagnosis or direct care of symptoms, sickness or injury to the patient, or for routine screening examination under wellness benefits;
- Ordered by the attending licensed physician or dentist and not solely for your convenience, your physician, hospital or other healthcare provider;
- Consistent with professionally recognized standards of care in the medical community with respect to quality, frequency and duration; and
- The most appropriate and cost-efficient treatment, service or supply that can be safely provided, at the most cost-efficient and medically appropriate site and level of service.
A treatment, service or supply must satisfy all of the criteria above to be considered Medically Necessary under the terms of the Health Plan. Even though a provider may order a treatment or test, the Health Plan will not cover it if it does not meet all four criteria listed above.
To learn about the Health Plan’s standards for medical necessity related to physical therapy treatment and labs and tests, read:
